Denial Management Program
Denial Management Process: The 4Clover Approach to an Effective Denial Management Program
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Denial Management Process: The 4Clover Approach to an Effective Denial Management Program
Denial management process can make or break your revenue cycle. It’s one of the most critical phases in the overall revenue cycle process that can have a significant impact on a Medical Practice’s revenues and cash flow.
Denial management process can make or break your revenue cycle. It’s one of the most critical phases in the overall revenue cycle process that can have a significant impact on a Medical Practice’s revenues and cash flow. The financial impact of claim denials could be costlier than you think. Consider these facts—
Failing to have a holistic approach to working on denials means lost revenue opportunities, while having a long-term negative impact on your Practice’s clinical, operation and financial efficiencies. This article discusses some of the nuances and integrities of a comprehensive denial management process—that can accelerate your revcycle performance, especially the denial management process.
A standard Denial management process can provide ad hoc solutions to some of the pressing denial challenges that need immediate intervention. However, for a more effective denial prevention strategy, you need to get to the root of the issue.
Root cause analysis is a significant step in denial prevention. Several hospitals and Practices leverage the capabilities of claim management software with automation solutions to simplify and improve efficiencies of the denial management process. Consider asking these critical questions to start with.
What are the key reasons for denials in your Practice?
24 hours is all it takes to
Your claim denials need to be categorized in order to segment them into Preventable and nonpreventable denials. This gives you actionable insights that help you focus on areas where opportunities exist, and allows you to be realistic and focus on preventable denials. Here’s how you can categorize your denials.
| Reason Code Description | Category | Preventable or Nonpreventable |
| Additional information requested | Documentation and coding | Preventable |
| Coverage not in effect at the time of service | Patient registration | Preventable |
| Exceeds maximum number of units | Documentation and coding | Preventable |
| Diagnosis not covered | Documentation and coding | Preventable |
| New patient qualifications not met | Documentation and coding | Preventable |
| No authorization | Patient registration | Preventable |
| Timely filing | Claims submission | Preventable |
| Non-covered | Documentation and coding | Non-preventable |
While the root cause analysis and denial categorization are amongst the significant processes of the initial phases of the denial management process, at SolvEdge, we have developed the extensive and comprehensive 4Clover Approach (Analyze, Strategize, Discover, Implement), a field-tested technique that’s proven to reduce and prevent denials from the ground up. Here’s how you can run a successful denial management program using the 4Clover approach.
Post implementation, it is essential that your denial management team continues to track and monitor new policies, denials performance and conduct periodic reviews of the newly implemented denial management program.
Our denial management services and strategies are uniquely designed to reduce the spiking denial rates, while having a proactive approach to denial prevention. Our customized workflows help determine the root cause of denials. Once the denial patterns are identified, we create a detailed report that evaluates the recurring causes of claim denials under various categorizations like the Payer, doctor, diagnosis and CPT codes. By leveraging these insights, we implement process improvements to reduce denials and optimize revenues.
Get your personalized and free consultation on how SolvEdge’s denial management services can help reduce your denial percentage and drive up your revenues and cash flow
From our humble beginnings as a healthcare start-up—to becoming a full-blown healthcare-exclusive digital transformation provider, our journey has been quite a remarkable one. Today, SolvEdge is a leading-edge Healthcare services and solutions provider—trusted by 450+ Hospitals, 3500+ Physicians and millions of patients across the globe.